Battling Heart Disease Risk In Diabetic Patients

Every year, 800,000 additional cases of diabetes are diagnosed and it is projected that nearly 9 percent of all Americans will have diabetes by the year 2025.1 More shockingly, the incidence of diabetes has gradually increased among young people over the last decade, mainly related to an increase in obesity and sedentary lifestyles. In addition, diabetes may commonly reappear in women who previously had gestational diabetes.2
Diabetes has truly proven itself to be a progressive Pandora’s box, which can cause severe complications such as heart disease, kidney disease, blindness and lower extremity amputations. The intricacies of the disease process and its effect on multi-organ systems have warranted a multidisciplinary approach. Simply put, a disease process without boundaries requires an unrestricted approach in its management. Otherwise, this disease process cannot be stopped but just managed.
One of the most troubling statistics is the fact that people with diabetes are two to four times more likely to have coronary heart disease (CHD) and stroke than people without diabetes.1 Indeed, heart attack is the biggest cause of death for people with diabetes. The disease process makes these patients prone to fatty deposits in their arteries, blood clots and a higher risk of high blood pressure, all of which can lead to heart attacks and strokes.
To manage this disease process effectively, an unconventional approach may be necessary. For instance, recently there has been increasing evidence that vitamin B3 (niacin) will play an integral role in reducing the incidence of heart disease, especially in people with diabetes. Researchers found that niacin produced favorable, cardio-protective results among people with heart disease risk factors.3,4 (See “Controlling Risk Factors” )

Rethinking The Reduction Of Heart Disease Risk
Abnormal lipid levels contribute significantly to the risk of coronary heart disease, which is increased further in the presence of other risk factors. The association between elevated low-density lipoprotein (LDL) cholesterol and CHD risk is well established and several studies have shown that lowering LDL cholesterol levels reduces CHD episodes and overall mortality.

LDL cholesterol reduction remains the cornerstone of CHD prevention. Statin therapy provides the most dramatic and consistent reduction in LDL cholesterol and CHD risk. You would pursue this treatment regimen with those who are at high risk for CHD. These high-risk patients have a history of preexisting atherosclerotic disease, diabetes or familial hypercholesterolemia. Statin therapy is generally found to reduce cardiovascular risk by 35 percent over five years of treatment. Other options for achieving LDL cholesterol goals include bile acid sequestrants, plant stanols and niacin.
While statins are commonly given to people with heart disease when diet and exercise do not sufficiently lower cholesterol, researchers now believe the addition of niacin can lower the risk for heart disease even further. Many of the patients with heightened risk for cardiovascular disease will require multi-level treatment regimens involving statins in concert with niacin, fibric-acid derivatives or bile acid resins.

Can Niacin Make An Impact?
Niacin (nicotinic acid) is one of the oldest drugs to treat high cholesterol. Niacin displays potent ability to lower LDL cholesterol and triglyceride levels and elevate HDL cholesterol levels. It is one of eight water-soluble B vitamins which help convert carbohydrates into glucose and are also essential in the breakdown of fats and protein.
At high doses, niacin has been shown to prevent and/or improve symptoms of high cholesterol, atherosclerosis, diabetes, osteoarthritis, cataracts and burns. In fact, a study conducted and published in JAMA found that niacin increased HDL levels by 29 percent, decreased triglycerides by 23 percent and LDL by 8 percent.3 Researchers also noted mild increases in glucose levels, although levels of HbA1C were unchanged from baseline.
The researchers also concluded that lipid-modifying dosages of niacin can be safely used in patients with diabetes and that niacin therapy may be considered as an alternative to statin drugs in treating patients with diabetes who cannot tolerate the statin agents.3
Another study comparing lovastatin with niacin concluded that niacin increased HDL by 16.3 percent compared to 1.5 percent for lovastatin and decreased triglycerides by 18.4 percent compared to 0.8 percent by lovastatin.6
Niacin is available in several different forms: niacinamide, nicotinic acid and inositol hexaniacinate. The form niacin is best tolerated with the least symptoms is inositol hexaniacinate. Niacin is available as a tablet or capsule in both regular and timed-release forms. The timed-release tablets may have fewer side effects than the regular niacin but are more likely to cause liver damage.
Niacin is contraindicated in patients with a history of stomach ulcers or liver disease and periodic liver function tests are recommended.
High doses of niacin can cause side effects such as “niacin flush,” which is burning, tingling sensation in the face, chest and red or “flushed” skin.5 However, researchers note that taking an aspirin 30 minutes prior to niacin may help reduce the symptoms.

Final Notes
Like most medications, niacin is not without its share of contraindications. However, its effects in lowering risk factors for heart disease far outweigh its potential side effects. Indeed, adding a vitamin to conventional lipid-lowering medications may prove, if used effectively, beneficial in lowering the risk of heart disease with diabetes.

Dr. Shah has a private practice in San Antonio, TX.

Dr. Steinberg (pictured) is an Assistant Professor in the Department of Orthopaedics / Podiatry Service at the University of Texas Health Science Center.

References:

References

1. Mokdad AH et. al.: Diabetes trends in the U.S.: 1990-1998. Diabetes Care 23(9), 2000.
2. Heart disease, https://www.diabetes/heartdisease.com.
3. Elam, MB et. al.: Effect of Niacin on Lipid and Lipoprotein levels and Glycemic Control in patients with Diabetes and Peripheral Arterial Disease: JAMA 2000, 284:1263-70.
4. Lavie, CJ et. al.: Marked Benefit with Sustained-Release Niacin therapy in patients with Isolated levels of High-Density Lipoprotein Cholesterol and CAD: AJ Cardiology: 1992, 69:1083-1085.
5. Cullen, P et. al.: Evidence that Triglyceride are an Independent Coronary Heart Disease Risk Factor: AJ Cardiology: 2000, 86:943-949.
6. O’Connor, PJ: Relative Effectiveness of Niacin and Lovastatin for treatment of dyslipidemias in A Health Maintenance Organization: J. Family Practice, 44(5):462-7, 1997.